Unsafe situation LTC

[Nik6lpn]

Any advice on how to handle being the charge nurse when you have a patient that is clearly not appropriate for LTC but there is nowhere else for her to go? The majority of your time is spent keeping 1 Resident safe, requiring 1 on 1, 100% of the time, unless she sleeping, which she does not sleep much. Behaviors include: punching, pinching, pulling hair, biting,standing up and attempting to walk which will result in a fall if you don't immediately assist. She takes the strongest psych med available for our use and the pcp will only prescribe tyl and Ibup for pain. She is clearly always in pain, c/o pain to back, and we believe that is why she constantly stands up, then sits, then stands, then tries to walk...etc. It is impossible to get through a med pass without being interrupted every couple seconds, taking her with you at times. He son said she has a hx of alcoholism and behaviors and is unable to come and visit her due to distance. Administration gaslight us saying she isn't that bad and there's nothing else we can do. She needs a sitter at the very least, but more appropriately, she needs a pschy unit. We do love her and she can be the sweetest person, but then mood flips sometimes out of nowhere and she becomes violent. Any helpful advice would be appreciated.  

[toomuchbaloney]

Do you have care conferences for your residents? This agitated and violent behavior should be formally addressed with the team. Is there a palliative case assessment of this patient? Is that a possibility in your region?

Good luck. You are in a tough spot and the owners know it.  Things will change when the owners are in a tough spot and not just their employees.  

[Nik6lpn]

Thank you so much for the reply.

We do have Care Conferences for the residents. Palliative sounds perfect for her, but I believe her POA refused it. I will look into that more. Maybe we can keep talking to her POA about it and educate her better on what it is and the benefits for the resident.  

[Nik6lpn]

The owners may be in a tough spot if they don't act soon. We are loosing staff because of the extra load on everyone and I don't think they want to pay anymore agency Healthcare than they already do. They are lucky here that we have had more regular staff than agency,  as all of there other building have more agency than regular staff. What can a Nursing home do when they have a resident that requires 1 on 1? They won't hire a sitter, and in the past I feel like they have told family they require 1 on 1, and we don't provide that, so they had to make other arrangements.  This resident needs a pschy facility or a Memory Care Unit at the least, but they said they won't be able to place her in one because she is on medicaid, and Memory Care Units don't take Medicaid residents. It's hard to tell what's true and what they are saying just to pacify staff. 

[Tenebrae, BSN, RN]

I'm reluctant to suggest adding to your paper work. 

Every staff assault, inappropriate behaviour etc incident form it. Continue to incident form it. 

This is a situation I wouldnt allow to continue without a strong paper trail

[Nik6lpn]

I truly appreciate the great advice, and I will take this advice. Anyone working in LTC/SNF long enough, know the many situations you encounter that become nearly impossible at times, and the level of critical thinking and improvising that goes into getting your job done, getting it done right and keeping everyone safe, making sure meds /txs are done ontime, monitoring behaviors, dealing with/documentation and notifications of falls, skin tears, resident to resident situations,  and so, so much more. Doing this, while you have someone that is constantly needing your full attention is nerve-racking and unsafe to say the least. I have seen posts on this site, with nurses concerned about med pass interruptions (very valid) now imagine a constant interruption. It is not safe for anyone. My aides do help with her when they can, but they have very important jobs as well and they are all at their wits end, ultimately it is the nurses responsibility to keep everyone safe and to document everything, so the nurse is always taking on this extra responsibility of preventing her falling, and keep her from engaging in a resident to resident situation. The Admin tells us to just let her be, and that we are hovering too much and they believe that's some of the problem. How are you suppose to let her be, when she is constantly trying to walk on her own (which would almost always result in a fall) or literally pulling on you for your attention (these are the good days) when she has bad days, it is that behavior, plus she is verbally and physically aggressive. There has to be an answer, there has to be more we can do, to get this resident the treatment/care she needs, so that she and everyone else are also given the time and care they need and deserve.  

[delrionurse]

The resident either needs a sitter or be transferred to an appropriate facility. Admin aren't the ones taking care of her so your concerns won't speed up the process. Maybe ask for an extra CNA to be her sitter until she is transferred or request another unit. Nurses aren't there to be abused.

[Nik6lpn]

You are absolutely correct.  Resident NEEDS a sitter and we have asked, and that is when we are "Gas lit" getting responses such as... "We don't have one on one", "you are all hovering over her" (then of course we reply that we don't want to hover, nor do we have time to hover) but if we don't hover, she is constantly trying to walk alone, stand/sit over and over and WILL fall. We are preventing falls and potential resident to resident incidents.  We explain this over and over and we get nowhere. I know this is because they can't/won't provide a sitter and we can't find anywhere to send her.  I just don't see how they can NOT provide an extra CNA or sitter, instead keep us in an abusive, unsafe situation.  We have had 2 CNA's put in notice to quit in the past week. Everyone is stressed to the max and very unhappy.  Thank you for your reply. I appreciate the validation. They really try to make us feel like we are just supposed to deal with this. 

[Duranie]

Tenebrae said:

I'm reluctant to suggest adding to your paper work. 

Every staff assault, inappropriate behaviour etc incident form it. Continue to incident form it. 

This is a situation I wouldnt allow to continue without a strong paper trail

It's actually a good idea, Tenebrae. Unfortunately, it will only be effective if every "carer" follows thru on the reports. It needs to be any staff who is interacting with the patient when an incident occurs from lowly 😉 patient techs to LVN's & RN's. Also OT/PT providers (if any), dining room staff, RT's, etc. 

The idea is to show a true snapshot of how unsafe it is for:

• the patient (who isn't receiving appropriate care 😢 simply because your facility is the wrong placement)
• the other patients/residents (who are potentially getting injured by the patient)
• and various ancillary staff [some (most?) of whom are not adequately trained and prepared to manage the patient's behavioral issues]

If only OP is making the reports, it's going to look like s/he is a "complainer" rather than being seen as an indication of a need for this patient to be moved to a higher acuity facility. (Or an appropriate acuity facility, however you want to think of it…).

But getting everyone else on board to add more work to their day? 🙄  Maybe .... *if* they're convinced that ultimately it will effectively lessen their workload. 🤷‍♀️

[Ash_Ashley1992, LPN]

no staff for a one on one aid to sit with her?

[Nik6lpn]

Thank you for the advice. We are encouraged to chart behaviors as they occur, or at least a daily snapshot.  My question is: If I am encouraging the staff to fill out incident reports for every incident with this resident,  what will admin think of this? Will they appreciate it or will they see it as going above them and being an employee they want to rid themselves of? I'm really not sure. Just would be good to know going into it. 

Thank you

[toomuchbaloney]

Nik6lpn said:

Thank you for the advice. We are encouraged to chart behaviors as they occur, or at least a daily snapshot.  My question is: If I am encouraging the staff to fill out incident reports for every incident with this resident,  what will admin think of this? Will they appreciate it or will they see it as going above them and being an employee they want to rid themselves of? I'm really not sure. Just would be good to know going into it. 

Thank you

How do you think they will view your efforts to force something that they have already said can't be done?